Benefits of Gastric Bypass in Diabetes Control Significant But Diminish Over Time

MedicalResearch.com Interview with:

Charles Billington MD Chief, Section of Endocrinology and Metabolism Minneapolis VA Health Care System Professor of Medicine, University of Minnesota 

Dr. Billington

Charles Billington MD
Chief, Section of Endocrinology and Metabolism
Minneapolis VA Health Care System
Professor of Medicine, University of Minnesota 

MedicalResearch.com: What is the background for this study? What are the main findings? 

Response: We wanted to know if adding gastric bypass to intense lifestyle and medical therapy would improve overall diabetes treatment as represented by the triple endpoint of blood sugar, blood pressure and cholesterol control. We found that adding gastric bypass did provide significant benefit at five years after surgery, but that the size of the benefit declined substantially from the first to the fifth year. We also found that gastric bypass did provide significantly better blood sugar control throughout the five years, but the rate of diabetes remission at five years was low. There were many more adverse events in the gastric bypass group. 

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Gastric Bypass: Half of Diabetic Patients In Remission 12 Years After Surgery

MedicalResearch.com Interview with:
Ted Adams PhD
Adjunct Professor, Internal Medicine
Adjunct Associate Professor, Nutrition & Integrative Physiology
The University of Utah 

MedicalResearch.com: Why did you decide to conduct this study?

Response: The primary aim of the study was to determine the clinical outcomes in patients who underwent gastric bypass surgery.

As NIDDK/NIH continued to fund the study, the aim was extended to determining the durability) long-term outcomes) of gastric bypass surgery when compared to non-surgical, severely obese patients.

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Most Gastric Bypass Patients Keep Weight Off After Surgery

MedicalResearch.com Interview with:

Matthew Leonard Maciejewski, PhD Professor in the Division of General Internal Medicine Department of Medicine Duke University School of Medicine Research Career Scientist and Director of the Health Economics and Policy Unit in the Center for Health Services Research in Primary Care Durham VA Medical Center

Dr. Matt Maciejewski

Matthew Leonard Maciejewski, PhD
Professor in the Division of General Internal Medicine
Department of Medicine
Duke University School of Medicine
Research Career Scientist and Director of the Health Economics and Policy Unit in the Center for Health Services Research in Primary Care
Durham VA Medical Center

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: No study based on a US cohort undergoing current procedures has examined weight change comparing surgical patients and nonsurgical patients for as long as we have. This is the first study to report 10-year outcomes on gastric bypass patients and compare them to matched patients who did not get surgery. At 1 year, gastric bypass patients lost 31% of their baseline weight compared controls who only lost 1.1% of their baseline weight. At 10 years, gastric bypass had lost 28% of their baseline weight.

We also compared weight loss at 4 years for Veterans who received the 3 most common procedures (gastric bypass, sleeve gastrectomy, and adjustable gastric banding). At 4 years, patients undergoing gastric bypass lost more weight than patients undergoing sleeve gastrectomy or gastric banding. Given that few high quality studies have examined sleeve gastrectomy to 4 years, the 4-year sleeve outcomes contribute to filling this important evidence gap as the sleeve gastrectomy is now the most commonly performed bariatric procedure worldwide.

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Both Gastric Banding and Bypass Surgery Reduce Medical Costs

MedicalResearch.com Interview with:
Kristina H. Lewis, MD, MPH, SM
Kaiser Permanente Georgia, Center for Clinical and Outcomes Research, Atlanta
Department of Population Medicine
Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts

Medical Research: What is the background for this study?

Dr. Lewis: The prevalence of severe obesity (BMI ≥40 kg/m2) in the U.S. is rising. This is concerning, because patients with severe obesity tend to be sicker and have higher healthcare costs.  Bariatric surgery produces substantial weight loss and remission of a number of obesity-related comorbidities, but there have been very few studies directly comparing current procedure types. This leaves patients, providers and insurers with little information to help them decide about the pros and cons of different surgeries.

We wanted to compare outcomes after two of the most common bariatric surgeries in the US – laparoscopic adjustable gastric banding (band) and laparoscopic roux-en-y gastric bypass (bypass). To do this, we examined commercial claims data from almost 10,000 U.S. band and bypass patients who were very similar with respect to age, gender, and medical conditions. We looked at what happened to these patients from one year before their surgeries through 3 years after surgery. We compared changes in medical costs and use of healthcare services before and after surgery.

Medical Research: What are the main findings?

Dr. Lewis: When performed laparoscopically, both gastric bypass and adjustable gastric banding appear to result in lower total medical costs after surgery.  Bypass patients see a greater immediate drop in prescription drug costs than band patients – this is not surprising given that we know that this surgery is more likely to induce weight loss and diabetes remission. Unfortunately, bypass patients also have an initial increase in emergency department visits after surgery that is not present for banding patients.

When we compared total annual medical costs between band and bypass, we found no difference between procedures in the first 2 years after surgery. But, by year 3, bypass patients’ total annual medical costs are about 16% lower than those for band patients.

Medical Research: What should clinicians and patients take away from your report?

Dr. Lewis: Patients and clinicians considering one of these procedures should see these findings as good news. On balance, it looks like, for a group of very sick patients whose annual medical costs are trending upwards before surgery, these procedures result in overall lower levels of healthcare use after they are performed. Deciding between the two procedures, or opting for even newer procedure types, such as sleeve gastrectomy, would require a conversation between patients and their providers about their specific medical needs and their personal health goals.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Lewis: Studies are needed that examine the newer “vertical sleeve gastrectomy” procedure in a similar fashion. That procedure has become very popular in the U.S. recently but very little is known about longer-term outcomes after it.  Also – formal cost effectiveness studies that weigh the costs of the procedures against any potential benefits to patients would be important to conduct.

Citation:

Lewis KH, Zhang F, Arterburn DE, Ross-Degnan D, Gillman MW, Wharam J. Comparing Medical Costs and Use After Laparoscopic Adjustable Gastric Banding and Roux-en-Y Gastric Bypass. JAMA Surg. Published online June 03, 2015. doi:10.1001/jamasurg.2015.1081.

 

Kristina H. Lewis, MD, MPH, SM, Kaiser Permanente Georgia, Center for Clinical and Outcomes Research, Atlanta, Department of Population Medicine,  Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts (2015). Both Gastric Banding and Bypass Surgery Reduce Medical Costs 

Need For Better Measure of Kidney Function in Severe Obesity

Dr. John C. Lieske, MD Mayo Clinic, Rochester, MNMedicalResearch.com Interview with
Dr. John C. Lieske, MD
Mayo Clinic, Rochester, MN

Medical Research: What are the main findings of the study?

Dr. Lieske: We followed 11 women before, 6 and 12 months after Roux en Y gastric bypass surgery.  The patients successfully lost weight as mean BMI fell from 46 kg/m2 preoperatively to 28 kg/m2 postoperatively.   Mean serum creatinine did not significantly change from baseline (0.8 mg/dl) to 12 months (0.7 mg/dl).  Hence mean GFR estimated by the CKD-EPI equation (eGFR) did not significantly change from 84 ml/min/1.73 m2 (baseline) to 90 ml/min/1.73 m2 (12 months).  However, GFR measured by iothalamate clearance (mGFR) significantly decreased from 108 ml/min/1.73m2 (121 ml/min) to 85 ml/min/1.73 m2 (90 ml/min).

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Diabetes: Gastric Bypass Surpassed Medical Management in Weight Loss and Metabolic Control

Su Ann Ding, MBBS Research Fellow Joslin Diabetes Center Boston, MassachusettsMedicalResearch.com Interview with:
Su Ann Ding, MBBS
Research Fellow
Joslin Diabetes Center
Boston, Massachusetts


MedicalResearch: What are the main findings of the study?

Answer: We conducted a randomized controlled trial comparing the effectiveness of Roux-en- Y gastric bypass with an intensive diabetes and weight management program. We recruited 38 obese individuals (BMI 30-42 kg/m2) with type 2 diabetes. Participants had suboptimal glucose control and mean diabetes duration of 10 years.

Both surgical and non-surgical interventions led to patients losing a clinically significant amount of weight and keeping it off for 2 years, with average loss of approximately 57 pounds (25% of initial body weight) for the surgery group and 13 pounds (6% of initial weight) for the lifestyle and medication modification group. Other important health goals also improved more in the surgical group, including improvements in blood sugar control, blood pressure and lipid levels which together may contribute to reducing risk of developing coronary heart disease.
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Gastric Bypass Surgery: Changes in Appetite, Taste and Smell

Mr. David Bowrey, MD FRCS (Gen Surg) MMedEd FHEA  Consultant General / Oesophagogastric Surgeon & Honorary Senior Lecturer, Dept Cancer Studies, Training Programme Director for Core Surgery, East Midlands South  University Hospitals of Leicester NHS Trust, Leicester Royal InfirmaryMedicalResearch.com Interview with:
Mr. David Bowrey, MD FRCS (Gen Surg) MMedEd FHEA 
Consultant General / Oesophagogastric Surgeon & Honorary Senior Lecturer, Dept Cancer Studies,
Training Programme Director for Core Surgery, East Midlands South
University Hospitals of Leicester NHS Trust,
Leicester Royal Infirmary

MedicalResearch.com: What are the main findings of this study?

Dr. Bowrey: Of 103 patients who had undergone Roux en Y gastric bypass surgery, changes in appetite, taste and smell were noted in 97%, 73% and 42% respectively. Seventy-three percent of patients developed aversions to certain types of foods, most frequently meat, starch and dairy produce. The change in taste sensation for the three common modalities of “sweet”, “salt” and “sour” was decreased in some patients and increased in other patients. Patients who experienced food aversions typically experienced more weight loss than patients not developing aversions.
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